BLOOD FLOW RESTRICTION TRAINING/ BLOOD FLOW

OCCLUSION TRAINING IN PHYSIOTHERAPY PRACTICE

–DR G DURGA PRATHAP

INTRODUCTION:

According to APTA, Blood flow restriction or Blood flow occlusion therapy/ training
is the scope of physiotherapy practice. Physiotherapists are the one, who has better
knowledge about training physiology and vascular anatomy. BFRT would be a better
practical tool that can be used safely to achieve maximum benefits in
musculoskeletal and systemic disorders. The major goal of BFRT is to train
individuals with or without any injuries by using the intensity of resistance. In order
to get greater strength gain (muscle mass) at least 60 to 80 % of 1 RM has to be
used but, it is not possible in a situation like post injuries, older individuals, or post-
surgical conditions. Using a blood flow restriction device or manually applied straps
helps to reduce the venous and arterial flow during low-intensity exercises (20 to
40 % 1 RM) proven as effective as high load exercises in improving strength and
endurance.

HISTORY:

Thanks to Dr. Yoshiaki Sato, who accidentally discovered the concept of blood flow
restriction while he was attending a religious festival in 1966. He was seated in knee
bent position for a longer time and felt like the pump same as with intense training.
He spent quite longer time developing it further through research. Now it has
reached worldwide with better practicality and many bodybuilders, athletes’ and
PTs using in their scope of practice. In PT practice it has greater advantages in early
injury/ surgical recoveries.

DR GD PRATHAP BFOT by DR GD pg. 1

 BASICS OF TRAINING PHYSIOLOGY:

Exercise prescription and application are fundamental in PT practice. Every PT

should be able to understand physiological aspects of training, following key points
to be considered before learning BFRT.

• Strength training (anaerobic) refers to resisted training to improve muscle

mass, power, and contraction ability against the external load or body
weights
• Strength training uses predominately anaerobic energy and stored glycogen
from the muscles
• To improve strength in any muscles without any injury, 60 to 80 % of 1 RM
should be lifted for 3 to 4 sets in (08 to 14 reps) with 2 min rest interval
• Strength training enhance type 2 a, b fibres with greater muscle mass gain
• During strength training usually muscle burning sensation with failure of
muscle contraction termed fatigue failure (lactic acid accumulation)
• Lactic acid is a waste product in the anaerobic energy system that causes
muscles to become more acidic. Studies show acidic muscles give a better
environment for anabolism.
• Aerobic form of training uses very less or no resistance with extended
repetition of joint movements
• Basically, endurance type of activities such as cycling, long-distance running,
and walking
• Endurance exercises use aerobic energy system and are commonly
prescribed for cardiovascular health and weight loss program
• Exercises with high repetition 30 + with very low intensity of resistance /
without resistance.
• Aerobic exercise improves VO2 max, improves cardiovascular health, and
has less impact on the musculoskeletal system

DR GD PRATHAP BFOT by DR GD pg. 2

 PHYSIOLOGY OF BFRT

➢ Strength training is the most effective form of exercise to improve

musculoskeletal health through achieving hypertrophic changes in muscles
➢ To get adequate strength and hypertrophy training should incorporate 70 % of
1 RM resistance should be used for more than 6 reps x 3 sets
➢ The higher load would not be safe to use in elderly or injured athletes and in
some cases of untrained persons
➢ BFRT uses less intensity (20 % 1 RM) to implement exercises to prevent
muscle atrophy, to improve muscle hypertrophy (similar to higher loads) by
restricting the arterial and venous flow
➢ Some evidence also suggests BFRT can be used as completely passive or
combined with neuromuscular electrical stimulations

THE MECHANISM BEHIND STRENGTH AND HYPERTROPHY GAINS ASSOCIATED

WITH BFRT CAN BE DUE TO:

1) Mechanical pressure on the muscle recruits more fast-twitch muscle

fibers which are responsible for strength and muscle mass
2) Increasing the amount of blood (venous) fooling inside the muscle may
cause muscle cell swelling, which may activate satellite cells to adapt.
3) Occlusion of blood flow may promote hypoxic stimuli to the cardiac
system enhances circulatory nitric oxide production
4) Fast-twitch muscles are very sensitive to hypoxia and lead to greater
muscle failure even with less intensity of resistance.
5) Metabolic stress produced by BFRT, high compared with without
tourniquet. It may produce more lactic acid accumulation. Lactic acid
drops muscle PH levels and leads to a burning sensation in the muscles
but, acidic environments are vital to activate more growth hormones and
insulin-like growth factors.
6) Training with BFRT, produces more muscle damages as high-intensity
training leads to Satellite cell activation for rebuilding the muscle fibers
by using protein synthesis mechanisms (GH and IGF are important in
these activities)
7) Additionally, BFRT also promotes vascular health by stimulating
endothelial growth factors in order to prevent hypoxia. Also, NO
production supports anabolism.
8) Recent evidence suggests testosterone response to exercise is greater
with BFRT when it is used by young adults.

DR GD PRATHAP BFOT by DR GD pg. 3

 9) Apart from muscular changes, BFRT also enhances collagen matrix
binding capacity in bone and reabsorption.
10) Venous congestion and cell swelling (Pump) also alter the protein
signalling pathways and enhance the diameters of white fibre.

DR GD PRATHAP BFOT by DR GD pg. 4

 APPLICATION:

Blood flow restriction pressure:

➢ 160 mmHg to 240 mmHg commonly studied in lower limb BFR

➢ 60 to 80 % arterial occlusion pressure (AOP) is needed in many individuals,
however, lesser AOP is sufficient in the upper limb.
➢ 60 % of AOP in brachial arteries is equal to 120 to 130 % of systolic BP in
pneumatic inflation cuffs while using wider cuffs (13 cm).
➢ For beginners, it is advisable to use less AOP with more repetition of
exercise to cause metabolic demand.
➢ Handheld Doppler US can be used (Radial, brachial, popliteal) arteries to
select adequate safe AOP.
➢ Muscular contraction during exercise also puts additional pressure and may
increase the firing rate of muscle fibers (Even less pressure like 50 mm Hg
increased muscle activation in EMG studies during elbow flexor exercises -
(Takarada et al. 2000).
➢ In most cases, pressure can be subjective/comfortable, and adequate
pressure to cause cell swelling (pump).
➢ Avoid pressure that causes neuropathic pain/numbness / cold extremities or
severe ischemic pain.
➢ Ideal arterial occlusion pressure 40 to 80% (untrained participants need less
pressure).
➢ Maximum venous outflow restriction should be achieved.

DR GD PRATHAP BFOT by DR GD pg. 5

Cuff material:

➢ Nylon, elastic (slightly better than nylon)

Cuff location:

• Can be used bilaterally or unilaterally

• For the upper body – Between deltoid and biceps
• For the lower body – just below to gluteal fold
• Use 4 limb occlusion in advance fitness and performance athletes
• 4 limb occlusions may put a lot of strain on the cardiovascular system
• BFRT cuff, straps cannot be used in any other areas due to inefficient in
restricting the blood flow and increased chances of nerve damage

DR GD PRATHAP BFOT by DR GD pg. 6

Cuff width:

➢ Wider cuff- lesser the restriction, needs more pressure application (240
mmHg)
➢ Narrow cuff- greater restriction in blood flow
➢ Studies used widths from 3 to 18 cm
➢ The ideal range in most cases would be 5 to 8 cm
➢ For the lower limb 13 cm approx.

DR GD PRATHAP BFOT by DR GD pg. 7

 DEVICES

Vascular Doppler (4+ MHz)

• You shall use the handheld Doppler to find out adequate and safer AOP
• Doppler probe must be used in clinical cases or elderly populations as they
are prone to vascular impairments.
• Doppler also can be used for calculating ABI -Ankle Brachial Index, any
insufficiency in the vascular supply of peripheral circulation BFRT will not be
applicable.
• To identify adequate safe pressure, the probe should be placed over the
brachial (UL) posterior tibial arteries (LL). In some cases, u shall place it
over the radial artery
• As you apply inflation make sure the arterial sound should not disappear.
• If you are unable to find a pulse it is likely to occlude the artery completely
and needs to reduce occlusion pressure immediately.
• In some cases, it is mandatory to check the pulse in between rest due to
adding on the pressure of muscle contraction and venous congestion.

DR GD PRATHAP BFOT by DR GD pg. 8

 Pneumatic cuffs with inflator

Automatic inflator (Personal Training System)

DR GD PRATHAP BFOT by DR GD pg. 9

 EXERCISE PROTOCOLS (RESISTED / AEROBIC EXERCISES)

Variables / Parameters Description

Load/ Intensity • Resisted exercise: 20 -30 % 1 RM
(Isometric contractions also can be
applied with or without NMES in
early rehab)
• Aerobic exercises: Less than 40 %
of Vo2 Max (Cycling, Treadmill walk,
Overground walk, swimming,
boxing)

Sets/ Duration • Resisted exercise: 3 – 4 sets of

exercises (isolated, combined)
• Aerobic exercises: Duration of 20
min of exercise, if used with 4 limb
occlusion 10 min.

Reps • Resisted exercise: 15-30, often

muscle failure with the volume of 75
reps
Rest interval • Resisted exercise: 30 sec – 60 sec
Reperfusion time • For any exercise, reperfusion
should be allowed by deflation of
cuffs for 3 to 5 min
Training frequency • 2 – 4 times a week, not to be used
during DOMS.
• For sports and performance -
always combined with traditional
training.
Muscle contraction: Relaxation time • Concentric 1: 2 Eccentric

DR GD PRATHAP BFOT by DR GD pg. 10

 PASSIVE/ACTIVE ASSISTED BFRT WITH NMES

Few studies have shown BFRT also can be used to reduce the impact of
immobilization especially disuse atrophy. Disuse atrophy is one of the common and
major problems due to inactivity, immobilization after injuries or surgeries.

In many lower limb surgeries, weight-bearing is restricted for a certain period of

time. This leads to progressive decondition of the musculoskeletal system locally.
Early mobilization and rehabilitation strategies are essential in preventing
irreversible muscle wasting. It is interesting that BFRT in acute MSK rehab,
promises better recovery with early weight-bearing and return to sports.

Takarada et all 2000/ Kubota et all 2008, 2011. Studies use BFRT as a completely
passive mode of application without using exercises after lower limb injuries and
bed rest in ICU. As per these studies, BFRT in early rehab during the immobilization

DR GD PRATHAP BFOT by DR GD pg. 11

period can be useful without even exercise. But, application of tourniquet was
applied multiple times per day for 2 weeks. The ideal application would be 5
minutes cuff application with 3 minutes of reperfusion at least 3- 4 times a day.

Another option to use BFRT as the passive mode is using with NMES and it delivers,
electrical energy inside the muscles to contract without any voluntary efforts.
NMES is widely used to prevent muscle wasting associated with immobilization and
can be combined with BFRT to enhance post-immobilization outcomes. Only a few
studies have been addressed this area by using BRT with NMES to increase muscle
hypertrophy without any exercises (Joshua T Slysz et all 2018, Toshiharu Natsume
2018) and the results are inconclusive. Future studies should be focused on clinical
applications of combined modes with detailed dosages.

DR GD PRATHAP BFOT by DR GD pg. 12

 GENERAL PRINCIPLES OF RESISTED VERSUS AEROBIC EXERCISES with BFRT

• The resisted exercise which targets hypertrophy and strength should be

progressive
• The load should be increased every 2 weeks (10 to 15 % of 1RM for non-BFRT)
• While using BFRT progression more than load pressure and reps can be
focused’
• According to changes observed, conventional strength training also (High
load) admitted
• Pressure changes (AOP) happen with the progression of exercises,
especially with resisted exercises due to acute cell swelling. Reduction of
cuff pressure may be recommended to feel comfortable while making reps
• Both, aerobic and resisted exercise with BFRT needs enough warm-up
before inflation of cuffs
• Clinical application of BFRT may need more frequency of the same exercise
rather the conventional application

DR GD PRATHAP BFOT by DR GD pg. 13

 BFRT IN OTHER CONDITIONS

DIABETICS AND NEUROPATHIES:

• BFRT has direct effects on muscle atrophy it may beneficial in preventing

muscle loss associated with chronic diabetics.
• Also enhanced endothelial growth factors promote better blood flow and
prevent or delay neuropathy associated with DM.
• Additionally, few studies find BFRT with resisted exercises improves insulin
sensitivity in type 2 DM (ClinicalTrial.gov)
• Exercise dosage, cuff pressure must be carefully selected in diabetic
neuropathy patients. All DM patients must be checked with ABI to rule out
PAD (Peripheral vascular disorders).
• Ideal exercise prescription should mix aerobic and resisted exercises
• And more focus on distal muscle strengthening (Hand, Foot)

HYPERTENSION AND CARDIOVASCULAR HEALTH:

• BFRT also proved a safe and better option to train hypertension patients with
aerobics and resisted training (Marlon Wong 2018) without any adverse
events.
• Resisted exercise using BFR is equally good as BFR using aerobic exercises.
• In early HTN elevated CRP, uric acids in blood may cause vascular
inflammation that leads to HTN. BFR is known to reduce BP through
increased levels of blood nitrates and enhanced endothelial growth factors.
Studies addressed hypotensive effects (7-10 mmHg) of acute BFR
predominant in healthy and HTN individuals. However long-term effects are
yet to be studied.
• Exercise itself causes increased SBP due to increased HR, and post-exercise
hypotension is observed in many individuals due to generalized
vasodilatation after exercise but it is less when compares without BFR
• During exercise, the initial rise of BP is due to withdrawal of parasympathetic
circulation, increased HR, and vasoconstriction to other non-performing
tissues. When exercise reaches its peak may influence vasodilatation of
performing muscles and causes hypotension in late phases
• Exercises such as walking, cycling, handgrip, air boxing, mild aerobic dances,
a combination of multiple muscle exercises using Thera tubes, bands 4 /
week are recommended.

DR GD PRATHAP BFOT by DR GD pg. 14

 • Here is the example of normal exercise without BFR, resisted and aerobic
exercises initially increase the MAP and reduction observed in the late phase
(JR MacDonald 2002).

OSTEOPOROSIS AND FRACTURE HEALING:

• ChristianLinero 2021 found the effectiveness of blood flow restriction with

low-intensity training on bone metabolism in post-menopausal women with
osteoporosis. Partial restriction of arterial flow during low-intensity exercise
increases venous congestion in working muscles. According to Wolf’s law
metabolic and mechanical load is essential for bone formation and fracture
healing.
• Increased venous pressure adding extra mechanical compressive and shear
force during muscular contraction causes greater benefits in demanding
bone mineralization
• BFR also increases GH secretion due to elevated levels of lactate and H ions
(acidic) and also contributes to utilizing collagen matrix (cathepsin K, and
matrix metalloproteinases)
• BFR in osteoporosis, aerobic exercises along with strength training should
be performed using combo exercises weekly 4 times.
• Repeated muscle actions and weight-bearing exercise can be applied to the
fracture site tolerance by using BFRT
• In acute (first stage) cases of fracture , BFRT is contra-indicated due to risk
of displacement and metabolic damage

COPD AND LUNG DISEASES:

DR GD PRATHAP BFOT by DR GD pg. 15

 • COPD causes impaired ventilation and gas exchanges. Dyspnoea on exertion
typically affects the quality of life and exercise participation
• It is unlikely to perform endurance and high intensity resisted exercise to
gain functional improvements. in such conditions, exercise with BFR can be
utilized to enhance muscular strength and vascular supply (Muscle’s oxygen
utility)
• Using low-intensity resisted and endurance exercise may be safe in COPD,
also using BFR would enhance muscle strength and mass and prevent loss
in COPD patients.
• However further studies are recommended in these areas.

SAFETY AND CAUTIONS

• The risk of thrombus formation from BFRT was studied well and found not
significantly affect a healthy population. However, people with a previous
history and prone to blood clots should consider avoiding BFRT.
• Excessive muscle damage (Rhabdomyolysis) is one of the rare problems in
the novice exercises population. BFRT may increase the risk of
Rhabdomyolysis if, the training was done at an exhaustion level, especially
with untrained people. It is better to avoid overtraining with BFRT in clinical
populations and people new to exercises.
• Exercise itself elevates the blood pressure in healthy people temporarily but,
when the cuff is inflated during BFRT it may cause an abnormal rise in BP.
People with uncontrolled high blood pressure, peripheral vascular disorders,
cardiac failure should not be trained with BFRT. However, in early HTN
patients, BFRT benefits in reducing BP by enhancing endothelial growth
factors.
• Contraindications: Peripheral vascular disorders, recent MI, poor
cardiovascular functions, peripheral neuropathy advanced stage, acute
injuries with bleeding risk, infected area of the body, excessive inflammation,
DOMS, etc.
• One min recovery test: HR recovery is essential for any exercise and it’s a
strong predictor of cardiac capacity and motility risk. Vegal reactivation is
essential in reducing HR after withdrawal of the given exercise. Delayed
recovery of HR has a strong correlation with cardiac disorders hence BFRT
would be risky. One min HR recovery test should be admitted prior to BFRT
application to eliminate the risks

DR GD PRATHAP BFOT by DR GD pg. 16

DR GD PRATHAP BFOT by DR GD pg. 17
 ANKLE-BRACHIAL INDEX CALCULATION AND ENSURING SAFETY

• A non-invasive procedure to rule out PAD (Peripheral Arterial Disease)

• Due to age and diabetics may cause poor blood flow as compared to UL
• Often these population complaints of lower limb fatigue and pain related to
the poor vascular supply
• BFRT can cause potential danger in these populations and every suspected
case must be tested with ABI
• Must test in patients with a history of DM, HTN, Cold extremities, sensory
impairments at LL, History of smoking, and cardiovascular disease.
• Testing methods:
1. The patient advised taking rest for at least 10 min
2. Place the patient supine
3. Measure BP in the upper limb (bilaterally, use Hand-Held
vascular doppler)
4. Record the pressure where pulses can be audible during the
deflation
5. Repeat the same procedures in the lower limb using posterior
tibial arteries

DR GD PRATHAP BFOT by DR GD pg. 18

 • Results:
Normal ABI is between 0.90 to 1.30. more than these values would be
considered arterial calcification and compromised blood flow.

OUTCOME MEASURES IN BFRT

1. Muscle strength
2. VO2 Max
3. Muscle mass
4. Bone mass
5. Pain tolerance
6. Weight bearing capacity
7. Range of motions
8. Blood pressure
9. ABI
10. Spo2
11. Serum lactic acid
12. Serum NO
13. Functional independence
14. Gait velocity and quality
15. Balance

PROTOCOLS AND EXERCISES USED WITH BFRT/BFOT

Common exercises used for BFRT

LL:

• Quad’s isometrics
• Quad’s extensions
• Gluteal squeeze
• Bridges
• Prone SLR

DR GD PRATHAP BFOT by DR GD pg. 19

 • Supine SLR
• Lat raises
• Lateral walks with loop bands
• KB abductions
• Squat band resistance abductions
• Leg press with Swiss balls
• Mini squat abduction (with wall support)
• Standing hams curls
• Stiff leg deadlift
• Heel sliders
• DB Quads extension
• KB swings
• Deadlifts
• Heel walk
• Toe walk
• Standing toe raise
• Mini band lower limb series
• Stepping
• Standing terminal extension
• Donkey calf raise
• Ball supported (side-lying) Hip ext. rotation
• Cycling
• Treadmill/ overground walk
• Ankle dynamic dance
• Post fatigue dynamic balance
• Stiff leg deadlifts (Hams)

UL:

• Wall push-ups/ normal push-ups

• Ball rolling on the wall for rotator cuff /shoulder/ scapular
• Biceps curls
• Chest press
• Handgrip ball squeeze
• Forearm/wrist exercises
• Air boxing
• Ball throw/catching
• UL bicycle ergometer
• Scapular push-ups

DR GD PRATHAP BFOT by DR GD pg. 20

 • Floor press/ supine scapular push
• Walks down
• Fatigue hold-dynamic stabilization on wobble surface
• Band rowing/ Chest press
• T band int, Ext rotation
• T band shoulder combo moves (Ext rotation-flexion, press) (Int rotation-press hold)
• Dynamic dumbbell shifts
• Dumbbell air shifts
• Triceps extension
• Mini-band clock exercises
• Tennis elbow exercises

FURTHER READINGS AND REFERENCES:

1. Christoph Centner, Patrick Wiegel, Albert Gollhofer & Daniel König (2018) 'Effects of
Blood Flow Restriction Training on Muscular Strength and Hypertrophy in Older
Individuals: A Systematic Review and Meta-Analysis
2. William R. Vanwye et al.., (2017) 'Blood Flow Restriction Training: Implementation
into Clinical Practice', International journal of exercise science.
3. Stephen D Patterson et all (2017) 'Blood flow restriction training: a novel approach
to augment clinical rehabilitation: how to do it', British journal of sports medicine

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